ABSTRACT Although recent research indicates that many Latino smokers are nondaily smokers or daily smokers who smoke at a low level (<or =5 cigarettes/day), almost no research has investigated the characteristics of low-level smokers because such individuals are typically excluded from clinical trial research.
The present study examined the associations of daily smoking level and demographics, tobacco dependence, withdrawal, and abstinence during a specific quit attempt among 280 Spanish-speaking Latino smokers (54% male) who participated in a clinical trial of a telephone counseling intervention. Daily smokers were classified as low-level (1-5 cigarettes/day; n = 81), light (6-10 cigarettes/day; n = 99), or moderate/heavy smokers (> or =11 cigarettes/day; n = 100). Data were collected prior to the quit attempt and at 5 and 12 weeks postquit.
Results yielded three key findings. First, smoking level was positively associated with the total score and 12 of 13 subscale scores on a comprehensive, multidimensional measure of tobacco dependence. Low-level smokers consistently reported the least dependence, and moderate/heavy smokers reported the most dependence on tobacco. Second, low-level smokers reported the least craving in pre- to postcessation longitudinal analyses. Third, despite significant differences on dependence and craving, low-level smoking was not associated with abstinence. Smoking level was not associated with demographic variables.
This is a preliminary step in understanding factors influencing tobacco dependence and smoking cessation among low-level Spanish-speaking Latino smokers, a subgroup with high prevalence in the Latino population.

[Show abstract][Hide abstract]ABSTRACT: Research in smoking is hindered by a lack of validated measures available in languages other than English. Availability of measures in languages other than English is vital to the inclusion of diverse groups in smoking research. To help address this gap, this study attempted to validate a Spanish-language version of the brief Wisconsin Inventory of Smoking Dependence Motives (Brief WISDM).

[Show abstract][Hide abstract]ABSTRACT: Research suggests that immigrant enclaves positively influence health behaviors such as tobacco use through supportive social networks and informal social control mechanisms that promote healthy behavioral norms. Yet, the influence of social cohesion and control on tobacco use may depend on smoking-related norms, which can vary by gender. This study examines the influence of neighborhood Latino immigrant enclave status on smoking and cessation among Hispanic men and women. Data from the Los Angeles Family and Neighborhood Survey was combined with census data to assess the relationship between immigrant enclaves, gender, and smoking using multilevel regression. The effect of the Hispanic enclave environment on smoking differed by gender. Living in an enclave had a harmful effect on tobacco use among Hispanic men, marginally increasing the likelihood of smoking and significantly reducing cessation. This effect was independent of neighborhood socioeconomic status, nativity, and other individual demographics. Neighborhood immigrant concentration was not associated with smoking or cessation for Hispanic women. Research, interventions, and policies aimed at reducing smoking among Hispanics may need to be gender responsive to ensure effectiveness as well as health and gender equity.

[Show abstract][Hide abstract]ABSTRACT: The prevalence of light smoking has increased among Latinos. The purpose of this study was to identify demographic and acculturation-related factors associated with very light smoking, defined as smoking 1-5 cigarettes per day (CPD), among Latinos in California and nationwide. Latino smokers in the 2007-2008 National Health and Nutrition Examination Survey (NHANES) or the 2009 California Health Interview Survey (CHIS) were analyzed. Logistic regression assessed factors associated with very light smoking. Among NHANES smokers, those born in Mexico or who lived fewer years in the US were more likely to be very light smokers than 6+ CPD smokers. Among CHIS smokers, those born in Mexico, in another Spanish speaking country, or who spent smaller percentages of their life in the US were more likely to be very light smokers. Findings from this study can be used to design tobacco control media campaigns that include very light smokers.

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death among Latino men and the second leading cause among Latino women ( National Cancer Institute [NCI], 2005 ). More-over, Latinos experience tobacco-related disparities associated with access to treatment, tobacco marketing, cultural and lan-guage barriers ( Bolen, Rhodes, Powell-Griner, Bland, & Holtzman, 1997 ), and receipt of physician advice to quit smoking ( CDC, 2000 ). Thus, research addressing tobacco use and dependence among minority groups such as Latinos has been identifi ed as a major public health priority ( Fiore et al., 2000 ; U.S. Department of Health and Human Services, 2001 ). Latino smokers may be relatively unique among racial/eth-nic groups with respect to nondaily, low-level daily (i.e., 1 – 5 cigarettes/day), or light daily smoking (i.e., 6 – 10 cigarettes/day; Fagan, Moolchan, Lawrence, Fernander, & Ponder, 2007 ; Okuyemi et al., 2002 ; S. H. Zhu, Pulvers, Zhuang, & Baezconde-Garbanati, 2007 ). Data from the National Household Survey on Drug Abuse (1991 – 1993) indicated that 27.4% of Latinos were low-level daily smokers, as compared with 18.4% of Black and 9.3% of White smokers ( Kandel & Chen, 2000 ). Unfortunately, low-level smokers have typically been excluded from random-ized clinical trials of smoking cessation interventions, perhaps due to perceptions of increased need for research among those with higher levels of tobacco consumption ( S. H. Zhu et al., 2007 ). However, because low-level smokers are at elevated risk of negative health outcomes when compared with former or never-smokers ( NCI, 1998 ), understanding the associations of low-level smoking with tobacco dependence, withdrawal, and cessation is an important public health aim and could lead to specifi c treatment approaches targeted at these smokers. Research suggests that cigarette consumption may be a proxy for physical dependence on tobacco, such that low-level smokers demonstrate less dependence than heavier smokers ( Kandel & Chen, 2000 ). As a result, low-level smokers are more likely to attempt to quit, to experience less withdrawal ( Shiffman, Paty, Gnys, Kassel, & Elash, 1995 ), and to maintain abstinence than are heavier smokers (cf., S. H. Zhu, Sun, Hawkins, Pierce, & Cummins, 2003 ). Likewise, research supports a comparative lack of withdrawal symptoms in low-level daily smokers attempting to quit ( Shiffman et al., 1995 ), as well as different smoking mo-tives among low-level smokers (e.g., situational factors or a de-sire for positive reinforcement), as compared with heavier smokers (i.e., withdrawal avoidance; Shiffman & Paty, 2006 ). However, little is known about how tobacco dependence and withdrawal differ between low-level and light smokers during a specifi c quit attempt or how these relationships might operate among Latino smokers, who harbor a higher relative proportion of low-level smokers than do other racial/ethnic groups. The relatively high proportion of Latino low-level smokers also has implications for treatment. The current guidelines for smoking cessation intervention ( Fiore et al., 2008 ) recommend pharmacotherapy and behavioral counseling. However, given that low-level smokers may be less physically dependent on to-bacco, pharmacotherapy might be less effective or ineffective. Moreover, little research has focused on the effi cacy of behav-ioral smoking cessation interventions among Latinos, and only a few studies have demonstrated a signifi cant treatment effect ( Lawrence, Graber, Mills, Meissner, & Warnecke, 2003 ; Wetter et al., 2007 ). Thus, more research on the development of effi ca-cious smoking cessation treatments for Latino smokers is need-ed, and information about dependence, withdrawal, and other smoking-related constructs can help to inform and direct the focus of those interventions. Given the uniquely high prevalence of low-level smoking among Latino smokers, the present study examined the associa-tions of daily smoking level with demographics, tobacco depen-dence, withdrawal, and abstinence during a specifi c quit attempt among Spanish-speaking Latino smokers. Methods Source of data Data were from Adiós al Fumar, a two-group randomized clini-cal trial evaluating the effi cacy of a culturally sensitive, proac-tive, behavioral treatment program for Spanish-speaking Latino smokers ( Wetter et al., 2007 ). Self-identifi ed Latino adult smok-ers residing in Texas who called the National Cancer Institute’s Cancer Information Service (CIS South Central offi ce) to re-quest Spanish-language smoking cessation assistance were eli-gible for enrollment in this study. Participants were recruited from several locations in Texas (e.g., Houston, San Antonio, El Paso, and the Rio Grande Valley) via paid media (television, ra-dio, newspaper, and direct mailings). Participants were enrolled from August 2002 to March 2004. There were 355 eligible callers during the study period. Of the 355 callers, 297 consented to participate (84%). Of the 58 callers who did not participate, 28 declined, 3 were ineligible, 19 were unreachable, and 8 provided incomplete data. Of the 297 participants enrolled in the original clinical trial, daily smoking level was undeterminable for 17 individuals and they were ex-cluded from the current study, yielding a fi nal sample size of 280 participants. Callers agreeing to participate in the study were contacted by project staff within 1 week of their initial call to the CIS to complete a verbal, audiotaped informed consent, and a baseline assessment. Follow-up assessment calls were conducted 5 and 12 weeks after the baseline assessment. Participants were ran-domly assigned to receive one of two telephone-based counsel-ing protocols as part of the clinical trial (standard vs. enhanced). Standard counseling consisted of the single CIS counseling ses-sion that had been delivered during the initial call to the CIS, plus an offer of Spanish-language self-help materials that would be mailed to the participant if preferred. The content of coun-seling, session length, and treatment duration were based on evidence presented in the U.S. Public Health Service’s Treating Tobacco Use and Dependence Clinical Practice Guideline ( Fiore et al., 2000 ). Enhanced counseling consisted of the original CIS call and three additional calls scheduled through postquit week 4, which incorporated motivational enhancement techniques ( Miller & Rollnick, 2002 ) into the guideline-based approach ( Fiore et al., 2000 ). Assessment and counseling calls were con-ducted in Spanish. Detailed information about the treatment protocol and outcome is available elsewhere ( Wetter et al., 2007 ). Measures and variables of interest Smoking level . Smoking level was assessed at baseline and de-fi ned by self-reported cigarettes smoked per day. Smoking level

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180Low-level smoking among Spanish-speaking Latino smokersclassifi cation was informed by S. H. Zhu et al. (2007) : low-level (1 – 5 cigarettes/day ), light (6 – 10 cigarettes/day), and moderate/heavy smokers ( ≥ 11 cigarettes/day). The separation of low-level and light smokers allowed for a detailed examination of po-tential differences in withdrawal, dependence, and abstinence among this particularly understudied end of the smoking-level spectrum. Demographic variables . Demographic measures collected at baseline included age, gender, educational achievement, marital status, annual household income, ethnicity, time in the United States, and language spoken at home. Several variables were di-chotomized: marital status (married vs. not married), household income ( ≤ US$20,000 vs. >$20,000), ethnicity (Mexican vs. other), time in the United States ( ≤ 10 years or >10 years), and language spoken at home (only Spanish vs. not only Spanish). Tobacco dependence . Tobacco dependence was measured at baseline with the Wisconsin Inventory of Smoking Depen-dence Motives (WISDM-68; Piper et al., 2004 ) and with single-item dependence variables (i.e., number of years smoked and dichotomized time to fi rst cigarette of the day [ ≤ 5 min or >5 min after waking]). The WISDM-68 is a comprehensive, multi-dimensional measure of dependence that yields an overall smoking dependence score as well as subscale scores for critical dimensions of dependence, including nonphysical indices of dependence (e.g., affi liative attachment, automaticity, and so-cial/environmental goads; Piper et al., 2004 ). Tobacco withdrawal . Tobacco withdrawal was measured at baseline and the 5- and 12-week postquit assessments with the Wisconsin Smoking Withdrawal Scale (WSWS). The WSWS in-cludes subscales for anger, anxiety, sadness, concentration dif-fi culty, craving, hunger, and sleep ( Welsch et al., 1999 ). Smoking abstinence . Abstinence was defi ned as a self-report of no smoking during the previous 7 days at the 5- and 12-week assessments. Biochemical verifi cation of abstinence was not per-formed due to the telephonic nature of the clinical trial. Data analyses Initial analyses investigated the associations of smoking level with demographic variables and single-item tobacco dependence variables. Chi-square tests were used for analyses involving cat-egorical variables, and analyses of variance were used for con-tinuous variables. Multivariate regression analyses were used to investigate the association of smoking level with tobacco depen-dence as measured with the WISDM-68. Both unadjusted and adjusted analyses were performed. Demographic covariates in the adjusted model included age, gender, educational achieve-ment, marital status, annual household income, ethnicity, time in the United States, and language spoken at home. Generalized linear mixed model (GLMM) regressions ( McCulloch & Searle, 2001 ) were conducted to assess the longi-tudinal association of smoking level with withdrawal (WSWS) from 5 to 12 weeks postquit, controlling for treatment group, demographic variables, abstinence, and baseline withdrawal. Finally, the associations between smoking level and absti-nence were assessed at static postquit timepoints using logistic regressions and controlling for treatment group, age, gender, educational achievement, marital status, annual household in-come, ethnicity, time in the United States, and language spoken at home. Results were examined using both completer-only (missing data from dropouts were maintained) and intent-to-treat (dropouts categorized as smokers) analyses. The complet-er-only analysis included 84% of the low-level, 83% of the light, and 83% of the moderate/heavy smokers included in the intent-to-treat analyses. The association between smoking level and abstinence over time was assessed using GLMM regressions. Results Participant characteristics Participants ( n = 280) were generally of low socioeconomic sta-tus. More than 50% reported less than $20,000 in total house-hold income per year, and approximately 50% reported less than a high school education. Almost two-thirds of participants reported that Spanish was the only language spoken at home, and slightly less than half resided in the United States for 10 years or less. We found no signifi cant relationships between smoking level and demographic variables ( Table 1 ). Tobacco dependence Low-level, light, and moderate/heavy smokers differed with re-gard to single-item tobacco-dependence variables (see Table 1 ). Low-level smokers smoked for fewer years and were more likely to wait longer to smoke the fi rst cigarette of the day. Similarly, smoking level was strongly associated with dependence mea-sured by the WISDM-68 ( Table 2 ). As the pattern of results in unadjusted and adjusted analyses was similar, only adjusted analyses are reported. Results indicated that smoking level was associated with the WISDM-68 total score and 12 of 13 subscale scores (see Table 2 ). Smoking level was not, however, associated with scores on the social/environmental goads subscale. Low-level and light smokers, respectively, reported signifi cantly less dependence than moderate/heavy smokers on all 12 of the sig-nifi cant subscales and on the total score. Low-level smokers re-ported signifi cantly less dependence than light smokers on eight subscales, as well as the WISDM-68 total score. Withdrawal In longitudinal analyses of withdrawal, smoking level was strongly associated with craving, F (2, 221) = 6.19, p = .0024, but not with other withdrawal symptoms. The low-level smoking group reported less craving than other groups at baseline and both postquit timepoints ( Figure 1 ). Abstinence Smoking level was not signifi cantly associated with abstinence in logistic regressions conducted at static timepoints (i.e., 5 and 12 weeks postquit), regardless of method of analysis (i.e., com-pleter-only or intent-to-treat; Figure 2 ). Similarly, smoking level was not signifi cantly associated with abstinence in longitu-dinal analyses. Discussion The present study was the fi rst to examine the associations of smoking level with demographics, tobacco dependence, with-drawal, and abstinence among Spanish-speaking Latinos during a

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181Nicotine & Tobacco Research, Volume 11, Number 2 (February 2009)specifi c quit attempt. Three key fi ndings emerged regarding low-level smokers, who were of particular interest due to their unique-ly high prevalence among Latino smokers. First, smoking level was strongly linked to the total score and 12 of 13 subscale scores on a comprehensive, multidimensional measure of tobacco de-pendence (i.e., WISDM-68) as well as single-item tobacco-de-pendence variables. In each case, low-level smokers reported the least dependence and moderate/heavy smokers reported the greatest dependence on tobacco. Second , in withdrawal analyses (i.e., WSWS), smoking level was associated with craving longitu-dinally from prequit to 12 weeks postquit, but not with other withdrawal symptoms. Low-level smokers reported the least crav-ing and moderate/heavy smokers the most craving at all points in time. Finally, smoking level was not signifi cantly associated with abstinence at static postquit timepoints or longitudinally. Thus, despite less dependence and fewer cravings, low-level smokers were not more likely than heavier smokers to quit smoking. The lesser levels of tobacco dependence reported by low-level smokers complement previous fi ndings about “ chippers ” (nondaily and low-level smokers) who manifest less (or no) de-pendence on nicotine, as compared with heavier smokers (for a review of research, see Shiffman & Paty, 2006 ). However, the present study extends that research to Latinos. Low-level and light smokers differed signifi cantly in self-reported tobacco de-pendence; low-level smokers reported less dependence than their light smoking counterparts. This fi nding highlights the importance of examining low-level and light smokers separate-ly, at least among Spanish-speaking Latino smokers. Given that smoking level was associated with 12 of the 13 subscales of the WISDM-68, the lack of association with the re-maining subscale, social/environmental goads, is of particular interest. Social/environmental goads assess contextual infl u-ences on smoking (e.g., social motives for smoking, smoking in the presence of other smokers), and the lack of association sug-gests that low-level smokers may be as motivated as light and moderate/heavy smokers to smoke in response to environmen-tal cues and social motives. These results complement fi ndings that chippers smoke for social reasons, or to enhance the enjoy-ment of activities, rather than in response to physiological with-drawal symptoms ( Shiffman, Kassel, Paty, Gnys, & Zettler-Segal, 1994 ; Shiffman & Paty, 2006 ). Moreover, low-level smokers re-ported signifi cantly less craving, both at baseline and during the quit attempt, than did light or moderate/heavy smokers, but they did not differ on any other withdrawal symptoms. Thus, results suggest that interventions for low-level Latino smokers need to be weighted more toward building the skills to combat smoking in response to social situations and activities, as well as altering environmental features to facilitate abstinence, rather than tolerating physiological dependence and craving. The po-tential effi cacy of pharmacotherapy among low-level Latino smokers deserves serious study given the reduced tobacco de-pendence and craving among this segment of smokers. Smoking level was not associated with abstinence during the quit attempt. This fi nding is notable because previous research indicates that low-level smokers are more likely than heavier smokers to maintain abstinence when quitting, perhaps due to reduced levels of, or the absence of, dependence on tobacco (cf. S. H. Zhu et al., 2003 ). Although low-level smokers were less dependent on tobacco and experienced less craving during the quit attempt than did light or moderate/heavy smokers, this did not translate into higher cessation rates. However, as shown in Figure 2, there was a suggestion, albeit nonsignifi cant, that low-level smokers might be more likely to quit successfully, and the present study may have simply lacked suffi cient power to detect the effect of smoking level on abstinence. Future research should Table 1. Participant characteristics at baseline Low-level smokers: 1 – 5 cigarettes/day ( n = 81)Light smokers: 6 – 10 cigarettes/day ( n = 99)Moderate/heavy smokers: ≥ 11 cigarettes/day ( n = 100) p value Demographic variable Age, years ( SD ) Gender (percent male) Education (percent) <High school ≥ High school to some college ≥ College Marital status (percent married) Household income (percent <US$20,000) Ethnicity (percent Mexican origin) Time in the United States (percent >10 years) Language spoken at home (percent Spanish only) Single-item tobacco-dependence variable Average number of cigarettes/day ( SD ) Number of years smoked ( SD ) Time to fi rst cigarette (percent ≤ 5 min) Treatment group (percent enhanced)

3.4 (1.4)19.5 (11.0)6.246.98.6 (1.6)21.7 (9.1)12.153.519.7 (7.8)24.5 (1.08)28.350.0<.001 .005 <.001 .674 Note. The p values for continuous variables are based on analysis of variance tests for differences between groups based on smoking level; p values for categorical variables are based on chi-square tests for differences between groups based on smoking level.